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  • 2020 Federal Advocacy Forum Coming March 29; Registration Open Through March 16

    While 2019 saw some real advocacy achievements for the physical therapy profession, the year also brought challenges to tackle in 2020 — not the least of which is the proposal by Medicare to cut reimbursement to physical therapy in 2021. And with APTA's fight against the cut already in motion, the 2020 Federal Advocacy Forum, set for March 29-31, couldn't come at a better time.

    Registration is now open for the annual event, which brings PTs, PTAs, and students together in Washington, DC, for a three-day conference that provides the latest on regulatory and legislative issues affecting the profession, and ends with an opportunity for attendees to apply what they've learned by making in-person visits to Senate and House offices. Registration deadline is March 16.

    The forum's keynote speaker will be Paul Begala, political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Begala's participation is in keeping with the forum's tradition of offering a variety of speakers with diverse perspectives. Past keynote speakers include political commentator Fred Barnes, FOX News host Tucker Carlson, and political strategist Donna Brazile.

    Other forum activities will include an evening reception and breakout sessions on advocacy-related topics.

    "The proposed 8% cut will be one of the issues the profession will share with their elected officials, and APTA will continue to educate Congress about the essential role that physical therapists play in the delivery of quality health care for patients of all ages across the country," said Michael Matlack, APTA's director of congressional affairs. "Now, more than ever, the voice of the physical therapy profession is critical to the health and well-being of our patients and our industry. "

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the Federal Advocacy Forum webpage.

    NCCI Code Edits: Your Questions Answered

    Background: A surprise coding change issued by the Centers for Medicare and Medicaid Services (CMS) caused an uproar in the physical therapy community earlier in January, and for good reason: The new requirements state that CMS won't reimburse for certain activity and evaluation codes if they're used in the same day. APTA argues that accepted physical therapist practice often includes the startup of care on the same day as evaluation (and continued care on the same day as reevaluation), and that the prohibition runs counter to CMS' own aims for care.

    Reaction: Since the announcement, Capitol Bridge, LLC, CMS' National Correct Coding Initiative (NCCI) contractor, has been inundated with comments from PTs, PTAs, and other stakeholders slamming the decision and requesting that the change be reversed. And it's not too late to add your voice to the effort. APTA is communicating with representatives from Capitol Bridge, CMS, and the American Medical Association, which plays a significant role in coding development.

    Where things stand: As of the date of this report, no changes have been made. That leaves PTs and PTAs to deal with the current prohibition, as problematic as it may be.

    To help you navigate the system as it is, here are answers to some of the most common questions we've been receiving on the NCCI coding change.

    1. What are NCCI Procedure-to-Procedure (PTP) code pair edits?
    NCCI PTP edits are intended to prevent payment of services that should not be reported together. Each edit has a Column One and Column Two Health Care Common Procedure/Current Procedural Terminology (HCPCS/CPT) code, called a “pair.” If a provider reports the two codes of a pair for the same beneficiary on the same date of service, only the Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

    As for modifiers, each PTP edit has a modifier indicator, represented by (0), (1), and (9), that appears after the code number. Here's what those numbers mean:

    • 0 - There are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
    • 1 - A modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this distinction provides the basis upon which separate payment for the services billed may be considered justifiable.
    • 9 – The deletion date of the code pair is the same as the effective date. In other words, these edits are no longer active, so the code combinations are billable, and no other modifier is needed.

    2. What happens if I bill 97530 (therapeutic activities) and 97161, 97162, or 97163 (physical therapy evaluations) together on same day for same patient?
    This is at the heart of the recent edit. Under the new rules, the use of both codes is prohibited, and there's no modifier that you can use to bypass the denial. That includes the 59 modifier/X modifier: You can't use the 59 modifier/X modifier when billing 97530 with 97161, 97162, or 97163 to bypass the edit.

    Bottom line: when 97530 and one of the physical therapy evaluation codes are billed together on the same day for the same patient, the evaluation code will be denied. This is because in the PTP edits list, 97530 is the Column One code and 97161, 97162, and 97163 are Column Two codes (see the answer to question 1 for more background on Column One and Column Two codes).

    3. Why is 97530 (therapeutic activities) in Column One and 97161-97163 (physical therapy evaluations) in Column 2?
    Good question. We believe this PTP edit is inconsistent with the general guidelines for PTP edits, and it's one of the reasons APTA and other stakeholders are working with CMS to have this edit removed as soon as possible.

    4. What happens if I bill 97150 (group therapy) and 97161, 97162, or 97163 (physical therapy evaluations) together on the same day for same patient?
    As with the therapeutic activities code covered in question 2, the answer is, you won't get reimbursed for the evaluation — and there is no modifier you can use to bypass the edit, including the 59 modifier/X modifier. This is because in the PTP edits list, 97150 is the Column One code and 97161, 97162, and 97163 are Column Two codes. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied.

    5. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97140 (manual therapy) and 97161-97163 (physical therapy evaluation codes)?
    Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code. This is because in the PTP edits list, 97161-97163 is the Column One code and 97140 is the Column Two code. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied — unless an appropriate modifier is used.

    6. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97530 (therapeutic activities) and 97164 (physical therapy re-evaluation)?
    Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).

    7. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97150 (group therapy) and 97164 (physical therapy re-evaluation)?
    Yes, for the same reason explained in questions 5 and 6.

    8. Do PTP edits apply across disciplines?
    Unfortunately yes, when services are billed under the same provider number. For example, if the occupational therapist performs 97530 on the same day as the PT who bills an evaluation code, the evaluation code will be denied if the services of both providers are billed under the same provider number (as in institutional billing).

    9. What settings do PTP code pair edits apply to?
    The NCCI edits consist of two provider-type choices of PTP code pair edits: practitioners and hospitals.

    By "practitioners," CMS means that the NCCI edits apply to claims submitted by physicians, nonphysician practitioners, and ambulatory surgical centers. This includes PT private practitioners.

    The definition of "hospital," for purposes of this edit, extends to outpatient hospital services and other facility services including, but not limited to, therapy providers in Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies for certain claims billed under Type of Bill (TOB) 22X, 23X, 75X, 74X, 34X.

    10. Do NCCI edits apply to all third-party payers?
    Yes and no. Technically, the NCCI edits only apply to Medicare fee-for-service, but the majority of commercial payers do use the NCCI edits in their systems, so there's a good chance you'll need to comply with the edits even if you aren't working with Medicare. Some workers compensation programs and self-insured plans may create their own edits.

    11. Are there other edits I should be aware of?
    Yes, there are many PTP edits for hospital and practitioner settings. The PTP edits are updated on a quarterly basis. To stay up to date, visit the CMS PTP Coding Edits page, scroll down to related links, and click on the appropriate setting link (Hospital PTP edit or Practitioner PTP edit) for the relevant time period.

    12. What happens next?
    APTA continues to pressure CMS to remove these edits. CMS has met with the NCCI contractor to discuss the edits and is working on a resolution. We hope to have additional information to share in the near future.

    Looking for additional information about NCCI edits? Visit the National Correct Coding Initiative Edits webpage or contact APTA at advocacy@apta.org.

    Small-Scale Study Finds Large-Scale Debt Among Recent DPT Grads

    In this review: The Debt Burden of Entry-Level Physical Therapists
    (manuscript e-published ahead of print in PTJ, December 2019)

    The message
    It's a limited study—based on a small number of respondents who are early-career APTA members in Florida—but the conclusions might sound familiar to recent graduates of DPT programs: The average amount of educational debt owed by entry-level PTs is equal to almost two years’ average salary, a 197% debt-to-income ratio. That's more than the average debt-to-income ratio for newly minted family medicine physicians and veterinarians, according to the study's author, and a burden that may affect a PT's choice of practice setting.

    The study
    The analysis was developed from surveys administered to members of the Florida Physical Therapy Association's Early Professional Special Interest Group (SIG) in 2016, all of whom were entry-level professionals (0-5 years after graduation) and practicing as PTs in Florida. The final results were based on responses from 86 individuals (out of approximately 350 PT SIG members) who answered questions related to income, amount of debt held, and clinical practice choices. The study asserts that the sample reflects "all major practice settings." The study was authored by APTA member Steven Ambler, PT, DPT, MPH, PhD.

    Findings

    • Average (mean) salary for respondents was $69,328. Salaries ranged from $55,000 in a school setting to $82,659 in a home health setting.
    • The most frequently reported debt amount related to the DPT ranged from $100,000 to $124,999, with "relatively small" amounts of pre-DPT or non-educational debt reported.
    • Monthly income dedicated to loan repayment averaged 10%—a figure that skewed lower because several subjects reported 0% repayment based on income-based repayment or loan repayment that had not begun. When those respondents were factored out, the average amount of income devoted to loan repayment per month was closer to 22%.
    • While 83% of respondents indicated that the setting itself was the most important factor in deciding where to practice, 28% said that debt was a barrier to practicing in the setting of their choice.
    • Overall, 57% of respondents acknowledged that student debt had affected their practice choice, with that relationship growing stronger as levels of debt increased.

    Why it matters
    The issue of student debt in general has grown in national prominence, with some studies showing that the levels of debt burden are affecting the overall US economy. Student debt for PTs and PTAs is a major focus for APTA, which views the cost of physical therapy education as a potential barrier to achieving greater diversity in the profession, and a burden that can contribute to burnout and attrition. The association has established a Financial Solutions Center that provides opportunities for loan refinancing as well as financial literacy. APTA also is advocating for federal programs, such as the inclusion of PTs in the National Health Services Corps, that would offer debt relief to participants.

    More from the study
    The 197% debt-to-income ratio identified in the study was more than double the estimated average ratio for family medicine physicians, which ranged from 80% to 90%, and surpassed the average debt-to-income ratio for veterinarians, which studies have estimated at 160% to 180%. Additionally, the average of 22% of monthly income spent on loan repayment among the PTs studied place them in a "hardship category of greater than 20% monthly income-debt ratio," which, Ambler indicates, has been shown in other research "to delay marriage and other personal decisions among young professionals."

    Keep in mind…
    The study has a small sample size, is limited to a single state, and is further narrowed by the fact that respondents were members of the state chapter of APTA and a particular special interest group. Further, the survey questions evaluated what the author describes as "personal, family, and institutional characteristics" that may offer further insights on debt burden. Finally, because information was collected via an anonymous survey, the author acknowledged that the results "are subject to selection bias."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Physician Owned? Corporate? Independent? Panel Event to Focus on PT Models of Practice

    Few would argue that health care in the United States has experienced significant change over the past few years—but do those changes require a new look at practice models for physical therapists (PTs)? That's the question at the heart of an event cosponsored by APTA and Arcadia University set for the evening of January 9, 2020, 6:00 pm–9:00 pm ET.

    The panel presentation, Practice Revolution: Physician Owned, Corporate, Health Care Systems, Independent, and More, will include presentations from APTA Chief Executive Officer Justin Moore, PT, DPT, and Bill Boissonault, PT, DPT, DHSc, APTA executive vice president of professional affairs, as well as APTA members Jennifer Gamboa, PT, DPT; Patrick Graham, PT, MBA; and Michael Horsfield, PT, MBA. The PT panelists will be joined by neurosurgeon Ryan Grant, MD, and Louis Levitt, MD, MEd, vice president of The Centers for Advanced Orthopaedics. Past APTA President Paul Rockar Jr, PT, DPT, MS, will serve as panel moderator.

    The event is open to the public—although RSVPs are required by January 2—and will be held in the Great Room of the University Commons at Arcadia, located about 14 miles north of Philadelphia. Remote participation is available. If you can’t attend in person but want to participate, select the option to participate remotely on the RSVP page. Login information will then be provided. The presentation will also be streamed live and recorded for later download.

    For more information, email stephensl@arcadia.edu.

    2020 Physician Fee Schedule Calculator Now Available

    It's back: APTA's members-only Medicare physician fee schedule calculator for 2020 is live.

    This year's calculator incorporates the 50% multiple procedure payment reduction (MPPR) as well as the overall 2% cut to Medicare payments implemented through sequestration. The calculator, delivered by way of an Excel spreadsheet, calculates Medicare physician fee schedule payment for procedures provided to a beneficiary on a given day in a specific geographic location.

    Other features include options for selecting your Medicare participation status—participating, nonparticipating but accepting assignment, or nonparticipating and not accepting assignment—as well as the ability to compare the 2020 payment rate with the rate in 2019. The calculator also features a Merit-based Incentive Payment System (MIPS) adjustment tool, which isn't applicable to physical therapists this year but will become a useful tool beginning in the 2021 payment year.

    APTA Helps You Prepare for Medicare in 2020, Fight Proposed 2021 Cuts

    Get ready, because Medicare is about to roll out some major changes in 2020. But that's not all: the US Centers for Medicare and Medicaid Services (CMS) is considering a potential estimated 8% payment cut for 2021. APTA wants to give you the tools you need to thrive and speak out for the profession.

    We've launched two new webpages designed to be one-stop shops—one for navigating the many Medicare rule changes affecting PTs and PTAs in 2020, and a second devoted to the profession's fight against the estimated 8% cut on the table for 2021.

    Both pages are packed with information and links to additional resources. The 2020 Medicare Changes page provides a general overview and then dives into topics such as the Quality Payment Program (home to the Merit-based Incentive Payment System, or MIPS), the physician fee schedule, PTA payment modifier, and coding updates. Our advocacy page on the proposed fee schedule payment reductions includes links to resources that will provide you with not only history and context, but with opportunities to advocate for the profession.

    Don't let 2020 take you by surprise. And help us challenge a nonsensical plan that could severely harm patient access to the care they need, when they need it.

    Trying to separate Medicare fact from fiction? Check out this #PTTransforms blog post from APTA Director of Regulatory Affairs Kara Gainer as she takes on some of the Medicare myths that have been popping up lately on social media and elsewhere. And stay tuned for part 2 of the series, coming soon.

    The New Postacute Care Payment Systems: 5 Tips to Help You Find Your Way

    There's no doubt about it: the new payment system that the US Centers for Medicare and Medicaid Services (CMS) put in place in October for skilled nursing facilities (SNFs), and the system that will start up for home health agencies (HHAs) on January 1, 2020, represent major changes by Medicare. And like most major changes, the new approaches have sparked myths, misunderstandings, and inaccurate interpretations—sometimes at the expense of physical therapists (PTs) and physical therapist assistants (PTAs) who work in the SNF and HHA settings and their patients.

    Discussions on what would become the new systems—the SNF payment model is called the Patient-Driven Payment Model (PDPM) and the HHA approach is known as the Patient-Driven Groupings Model (PDGM)—began 3 years ago, and APTA immediately began a dialogue with CMS that continues to this day. Those interactions, fueled by strong grassroots efforts among APTA members and other stakeholders, have helped to shape final rules that are far from perfect but significantly less problematic than many of the early proposals from CMS.

    The reality, however, is that PDPM and PDGM are here, and PTs and PTAs must now learn how to navigate the changed landscapes—and help dispel misunderstandings. Here are 5 things to remember about the new systems.

    1. PDGM and PDPM are changes to payment, not benefits. While some in the postacute care industry have characterized the new systems as a shift in benefit requirements, that's just not true. CMS expects that providers working in both systems—including rehabilitation professionals—will continue to use their clinical judgment to deliver high-quality therapy services that are reasonable and necessary. APTA communicates with CMS regularly on what we hear from members about employers' mischaracterization of the new rules—and CMS is listening (see tip 5).

    2, APTA offers multiple ways to learn more about the models. In addition to our advocacy efforts, we've developed free, publicly available education on the PDPM and PDGM: how to prepare for the changes, as well as how to advocate for and demonstrate the value of the PT and PTA within the new models. If you'd like to dig even deeper and find out what your peers are thinking about the models, check out this free downloadable recording of a recent webinar on postacute care reforms and the continued value of PT practice. A follow-up live Q&A is scheduled for December 13 at 1:00 pm, ET.

    3. PDGM and PDPM don't change what's important to practice. Any new payment system can be subject to misapplication—whether purposeful or not. But those misapplications should never affect the profession's commitment to ethical practice and the prevention of fraud and abuse. APTA's Center for Integrity in Practice website helps you better understand these issues in the context of best practice and reduced risk.

    4. The new systems may open up opportunities. Can changes to payment systems actually strengthen the case for rehabilitation services? Mahmood Iqbal, PT, thinks so. In a two-part blog series for APTA's #PTTransforms (part 1, part 2) this PT and HHA CEO takes a close look at the PDGM and sees a path that could make the role of the PT even more central to care. And while the posts focus on the home health setting, many of Iqbal's observations apply to PDPM as well. Want more perspectives on how to get the most out of the new models? Check out resources from APTA's Home Health Section, the APTA Academy of Geriatric Physical Therapy, and the association's Health Policy & Administration Section.

    5. CMS is watching—and we're listening. As the rules were being debated and developed, one of APTA's major areas of focus was around ensuring that CMS pays careful attention to utilization and outcomes. Our efforts, and the efforts of our collaborators at the American Occupational Therapy Association and the American Speech-Language-Hearing Association have resulted in CMS establishing regulatory guardrails that help to ensure that patients continue to receive the care they need.

    At the same time, APTA is committed to supplying CMS with on-the-ground information about how PDPM and PDGM are working for individual professionals. Your story is important—reach out to advocacy@apta.org to share your experiences.

    Getting a Handle on the Fee Schedule: 6 Things to Know About the New PTA Modifier and Estimated 2021 Cut

    The physical therapy profession can breathe a little easier after convincing the US Centers for Medicare and Medicaid Services (CMS) to back off from some of its more troubling proposals around work done by physical therapist assistants (PTAs) in the final 2020 Medicare Physician Fee Schedule (PFS). But the rule still includes policies that are cause for concern for many in the physical therapy community: notably, a planned cut that's estimated to reduce payment to physical therapists (PTs) by 8% in 2021, as well as a system that will eventually pay less for services delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA).

    In short, the 2020 PFS is a big deal. And at more than 2,400 pages, it's also just plain big, with several major components that affect PTs and PTAs in both good and bad ways, and plenty of context behind the details.

    You can read the entire rule to see for yourself, but before you do, here are 6 concepts that can help you understand what the profession is facing when it comes to the PTA modifier and estimated reimbursement cut in 2021.

    1. The application of the PTA and OTA modifiers were required by law—and will be broadly applied.
    The seeds that grew into the CMS rule requiring the use of modifiers were planted in 2018, when Congress passed (and the President signed) the Bipartisan Budget Act. The law required CMS to establish a system to denote when outpatient physical or occupational therapy services were furnished "in whole or in part" by a PTA or OTA, and beginning in 2022, to use that system to reimburse services at 85% when that "in whole or in part" line was crossed. The requirement applies to payments for physical therapy in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.

    2. The modifier system could have been a lot worse than what's in the final rule. APTA members were a big reason for the improvement.
    When CMS proposed how the modifiers would be used—"CO" for OTAs and "CQ" for PTAs—it forwarded an needlessly complicated system that threatened patient care and ignored the realities of PT practice (this PT in Motion News story outlines the problems with the proposed rule from APTA's perspective).

    APTA members, association staff, and other organizations pushed back hard by way of thousands of responses to the agency. CMS took notice, and while it hung on to its "de minimis" standard that the codes must be used when 10% or more of the service is delivered by a PTA or OTA, it backed away from many of the more problematic elements of its proposed plan. This is how the modifier process will work:

    • The CQ or CO modifier is required to be affixed to the claim line of the service alongside the respective GP or GO therapy modifier. Claims that aren't paired appropriately will be rejected.
    • The CQ/CO modifier doesn't apply if all units of a procedure code were furnished entirely by the therapist. The modifier requirement does apply when all units of the procedures code were furnished entirely by the PTA or OTA.
    • Only the minutes that the PTA spends independent of the PT count toward the 10% standard.
    • The 10% standard is applied to each billed unit of a timed code (as opposed to all billed units of a timed code as CMS originally proposed), and the system allows for 2 separate claim lines to identify where the CQ/CO modifier does and does not apply.

    Need more information? Join APTA for a live Q and A session on the modifier system on December 3, and prep for the event by reviewing a pre-recorded presentation now available. And keep an eye out for a quick guide to the CQ modifier coming soon to apta.org.

    3. The 8% cut is an estimate based on an attempt to maintain "budget neutrality” and is proposed for January 1, 2021.
    There are 2 main concepts at the heart of the planned 8% cut: the complex nature of relative value units (RVU), and the idea that in order to provide additional money to 1 area in the fee schedule, CMS must pull money from other areas (budget neutrality).

    RVUs are the basic unit of payment in the feel schedule, and they're established by way of a formula that involves values for work, practice expense (PE), and malpractice (MP), adjusted for geographic costs variations and multiplied by a conversion factor (CF). In the final 2020 fee schedule, CMS sets out a plan to increase work values for office and outpatient evaluation and management (E/M) codes, mostly used by physicians. That adjustment would raise overall RVUs for E/M services.

    The problem is that as far as CMS is concerned, giving several codes more money means giving other codes less. CMS' approach—strongly opposed by APTA and organizations representing 35 other professions facing cuts—is to simply devalue elements that are used to calculate RVUs in other areas. The agency asserts that it can't say with certainty that the estimated cuts will be the reality of payment in 2021 because it's waiting to see how other budget adjustments might affect the fee schedule's overall bottom line in 2021.

    4. Opposition to the RVU plan was far-ranging, strong—and largely ignored by CMS.
    The physical therapy profession wasn't singled out for a cut to pay for increased E/M reimbursement. Among the 36 professions affected, estimated cuts include a 7% decrease for emergency medicine, a 7% cut to anesthesiology, a 6% reduction for audiology, and 9% and 6% drops in payment for chiropractors and clinical social workers, respectively. CMS was flooded with messages opposing the cuts, including a letter initiated by APTA that was signed by 55 members of Congress. In its final rule, CMS briefly acknowledged the opposition and said it will address the criticisms in future rulemaking.

    5. APTA is aggressively fighting the cut, and all options are on the table.
    APTA is evaluating its advocacy options and refining its strategy for addressing the cut. We already know that any approach must involve working with other affected professions as well as mobilizing individual APTA members to add their voices to a grassroots campaign to let CMS know how the cuts could decimate care and put patients at risk.

    In fact, the effort has already begun. Visit the APTA action center to send a message opposing the 8% cut to your representatives on Capitol Hill—it only takes 2 minutes.

    6. APTA wants you to be prepared for what's coming soon.
    While the 8% cut remains an unsettled issue, there are plenty of elements of the 2020 fee schedule that will begin in January. The association and its regulatory affairs staff have already created several resources, with more on the way. Available now:

    APTA Regulatory Review: Final Physician Fee Schedule for 2020. The big picture, more on the CQ modifier and estimated cut, plus an overview of other elements in the PFS, including the Merit-based Incentive Payment System (MIPS), KX modifiers, remote monitoring, dry needling, and more.

    Live Q and A on CQ modifier, December 3, 12 Noon (ET). Download a pre-recorded presentation and submit your questions in advance for a detailed discussion focused on the new PTA code modifier.

    Live Q and A: The Changing Landscape of Federal Payment, Coverage, and Coding Policies, December 10, 1:00 pm – 2:00 pm. Download a pre-recorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the PFS, MIPS, TRICARE, and more.

    Insider Intel: PFS, MIPS, and more. A recording of a November 20 phone-in session with APTA regulatory affairs staff that touched on a wide range of payment topics, many related to the PFS.

    Information on the updated KX modifier thresholds and exceptions. The 2020 PFS includes a slight increase in the limits on therapy provided before the KX modifier is applied. Learn more here.

    Coming soon: a written guide on how to apply the CQ modifier, a webpage devoted to the 2020 Medicare changes, a 2020 multiple procedure payment reduction (MPPR) and sequestration fee schedule calculator, advocacy information on fighting the 8% cut, and more.

    US House Approves Bill to Help Fund Greater Diversity in PT, Other Health Care Education Programs

    APTA-supported legislation to encourage greater diversity in physical therapy programs has cleared an important hurdle: this week, the US House of Representatives passed a bill that would appropriate additional federal money for scholarships and stipends for students from underrepresented populations. Next stop—the US Senate.

    The bill that passed the House unanimously, called the "Educating Medical Professionals and Optimizing Workforce Efficiency and Readiness for Health Act" ( HR 2781) broadly focuses on educational issues in health care. Included in that bill was the Allied Health Workforce Diversity Act of 2019, a bill that specifically targets education programs in physical therapy, occupational therapy, audiology, and speech-language pathology. The diversity act was sponsored by Reps Bobby Rush (D-IL) and Cathy McMorris Rodgers (R-WA) and strongly supported by APTA.

    The diversity act would provide grants for use by accredited education programs in physical therapy, occupational, therapy, audiology, and speech-language pathology. The funds would allow programs to issue scholarships or stipends to students from racial and ethnic minorities, as well as to students from disadvantaged backgrounds including economic status and disability. That bill was included in its entirety as part of the broader health care education package.

    The provisions are consistent with APTA's strategic plan, which identifies greater provider diversity as necessary to ensure the long-term sustainability of the physical therapy profession. APTA, the American Occupational Therapy Association,the American Speech-Language-Hearing Association, and the American Academy of Audiology are working together to press for adoption.

    "The idea that health care professions should be as diverse as the populations they serve is an important one for APTA, and this legislation is a welcome step in the right direction," said APTA President Sharon Dunn, PT, PhD. "Diversity strengthens our profession, which in turn makes us better able to meet the needs of our patients and clients. That diversity must include the education programs that are creating the next generation of physical therapists and physical therapist assistants."

    “We are grateful to Representatives Bobby Rush and Cathy McMorris Rodgers for their leadership and support in getting this bipartisan bill through the House of Representatives,” said Justin Elliott, APTA vice president of governmental affairs. “We are also grateful to all of the APTA members who advocated in support of this important legislation.”

    A companion bill is expected to be introduced in the US Senate on Wednesday, October 30.

    The legislation is just one of several bills and issues APTA is advocating on during this session of the US Congress, which includes APTA-supported legislation aimed at addressing administrative burden and prior authorization (HR 3107), PT student loan debt (HR 2802/S. 970), home health payment issues (S 433 / HR 2573), Medicare fee schedule, self-referral, and more.

    APTA: New SNF Payment System Should Drive Quality Patient Care, Not Staff Layoffs

    Fewer than 48 hours after the launch of a new Medicare payment system for skilled nursing facilities (SNFs), APTA began receiving word from physical therapists (PTs) and physical therapist assistants (PTAs) that a number of providers were announcing layoffs or shifts to PRN roles with reduced hours and fewer or no benefits. Many were told by their employers that the new system, known as the Patient-Driven Payment Model, or PDPM, was the reason for reduced staffing levels and less therapy.

    There's one problem with that explanation: it isn't true.

    That's the message APTA is delivering to SNFs, association members, and the media as it works to debunk myths surrounding a system that was designed to support clinician decision-making and push SNFs toward a more patient-focused payment model.

    "Yes, this is a new payment system, but it doesn’t change the reality that staffing and service delivery must continue to be grounded in quality patient care," said Kara Gainer, APTA's director of regulatory affairs.

    What PDPM changes—and what it doesn't
    The US Center for Medicare and Medicaid Services (CMS) describes the PDPM as an attempt at "better aligning payment rates…with the costs of providing care and increasing transparency so that patients are able to make informed choices." In that sense, PDPM is another step in the overall evolution of health care toward a more outcome-based, patient-focused system. And it didn’t arrive out of nowhere: CMS has been floating proposals for revamping SNF payment since at least 2017.

    Still, the new system, with its basis on classifying SNF residents among 5 components (including physical therapy) that are case-mix adjusted and employing a per diem system that can be adjusted during a patient's stay, marks a big change for SNFs. For SNFs that embraced volume-based approaches to care, the shift is even more significant.

    That may be true, Gainer said, but some of the most important elements of PDPM are the things that haven't changed under the new system.

    "Absolutely nothing changed between September 30 and October 1 [the startup date of PDPM] about patient needs in SNFs, or the value of physical therapy in meeting those needs," Gainer said. "PDPM is predicated on the idea that rehabilitation professionals will exercise clinical judgment and furnish reasonable and necessary services to patients."

    APTA created a 1-page handout that summarizes what's different about the PDPM—more patient focus, reduced administrative burden, a new definition of group therapy and a 25% combined limit on group and concurrent therapy, and a new way to determine function scores—but the resource also points out what remains unchanged: medically necessary care as a baseline standard, the criteria for skilled therapy coverage, and the centrality of clinical judgment, among other elements. Additionally, the need for daily skilled nursing services or rehabilitation services has not changed.

    The bottom line, according to Gainer, is that decisions that override clinical judgment and reduce or compromise patient care shouldn't be attributed to any requirements contained in PDPM.

    "Assertions that the PDPM mandates cuts in care are untrue, as are claims that PDPM requires the maximum use of group or concurrent therapy, sets out productivity requirements, and dictates how many minutes of care therapists can provide based on payment categories," Gainer said. "Whether deliberate or simply a misinterpretation of the rule, these myths need to be put to rest."

    A big incentive for SNFs to get past the myths: CMS is paying attention
    As APTA members began sharing their stories of layoffs and status shifts attributed to PDPM, APTA President Sharon Dunn, PT, PhD, took to Twitter with a simple message:

    "PDPM changed Medicare payment methodology for SNFs on Oct 1. It did not change the value of physical therapy services or patient needs. Reducing PT and PTA staff 46 hours into this model reflects poorly on the commitment to patient access and quality of care. And CMS is watching."

    SNFs should pay particular attention to the last sentence of Dunn's tweet, Gainer said.

    "Anyone who's followed CMS rulemaking over the past few years knows that patient outcomes data and their link to plans of care are becoming extremely important in how CMS shapes payment and other rules—and rightly so," Gainer said. "CMS has already indicated to us that they are closely monitoring the actions of health care facilities post-PDPM to determine if patient needs are driving decision-making, and may propose changes to counter any trends that impede the overall goals of the system."

    In an interview for an article on PDPM published in Skilled Nursing News, Robert Lane, a consulting director for health care consulting firm BKD, called the SNF layoffs and adjustments "premature," and stated his surprise that the SNFs didn't "pump the brakes a little for 90 days to see where we're at after the first quarter, couple of billing cycles."

    And like Gainer, Lane told Skilled Nursing News that it's certain the sudden drastic changes will "draw attention from CMS."

    APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have issued a joint statement noting that they have shared reports of layoffs directly with CMS and will continue to keep the agency abreast of reductions that put patients at risk.

    APTA's continued work
    The first versions of what evolved into PDPM emerged in spring of 2017, and APTA immediately began advocating to CMS on behalf of patients and the physical therapy profession. The association's efforts, fueled by member engagement, led to some significant changes to the final rule—including CMS' decision to implement a combined limit of 25% of group and concurrent therapy.

    But now, with PDPM in place, APTA's efforts need to shift to careful monitoring of how the rule is being interpreted and implemented, and its impacts on patient care and the PTs and PTAs providing that care. The reason is simple, according to Gainer: rules can be changed.

    "Another myth that's being circulated is that the PDPM is now written in stone and that no adjustments can be made," Gainer said. "That has never been the case with rules from CMS, and certainly isn't the case with this system—especially given the amount of attention CMS will be paying to how SNFs interpret and implement PDPM, and the degree to which those changes impact patient access to medically necessary care."

    Get the facts on PDPM and stay up-to-date on news about the new system: visit APTA's Skilled Nursing Facility and Home Health Payment Models webpage. Do you have your own story about how the PDPM has affected your work? Contact advocacy@apta.org.